Reflections on battered women: gender violence and mental health. (Consequences of Gender Violence).IntroductionAlthough gender-based violence is far from being a new phenomenon, recent events have played a decisive role in bringing it to light and shifting it from the private to the public realm. Of particular importance was the United Nations General Assembly's "Declaration on the Elimination of all Forms of Violence against Women," approved in December, 1993 (Res. A.G. 48/104), as well as the Fourth World Conference on Women The United Nations convened the Fourth World Conference on Women on September 4-15, 1995 in Beijing, China. Delegates had prepared a Platform for Action that aimed at achieving greater equality and opportunity for women. held in Beijing in September, 1995. In a recent article we described in detail the visibilization of domestic violence (Bosch and Ferrer, 2000). For the purposes of this article, we will use the definition of gender-based or sex-specific sexual violence published recently in the glossary of the European Commission European Commission, branch of the governing body of the European Union (EU) invested with executive and some legislative powers. Located in Brussels, Belgium, it was founded in 1967 when the three treaty organizations comprising what was then the European Community (1999) as "any form of violence by the use or threat of physical or emotional force, including rape, wife battering, sexual harassment sexual harassment, in law, verbal or physical behavior of a sexual nature, aimed at a particular person or group of people, especially in the workplace or in academic or other institutional settings, that is actionable, as in tort or under equal-opportunity statutes. , incest and pedophilia pedophilia, psychosexual disorder in which there is a preference for sexual activity with prepubertal children. Pedophiles are almost always males. The children are more often of the opposite sex (about twice as often) and are typically 13 years or age or younger; ." The World Health Organization, at its 44th World Health Assembly held in May 1996, recognized in a resolution (WHA WHA World Health Assembly WHA World Hockey Association (merged with the National Hockey League in 1970s) WHA Western Hemisphere Affairs (US Department of State) WHA World Headache Alliance 49.25) the important increase in the incidence of intentionally-inflicted injuries which affect people of all ages and both sexes, but in particular women and children. The Assembly declared that violence against women is a public health priority because of its serious immediate and long-term consequences for individuals, families and communities. The following year WHO adopted a new resolution (WHA 50.19) insisting that violence against women is a social and sanitary problem of the highest magnitude that requires urgent action. According to according to prep. 1. As stated or indicated by; on the authority of: according to historians. 2. In keeping with: according to instructions. 3. WHO (1998a), violence against women is a priority issue for health professionals for the following reasons: Although its nature as a "hidden crime" makes the true dimensions of violence hard to ascertain (WHO, 1998b; n.d./1999), at least 20% of all women are estimated to suffer in some way as a result of violence. The available data provided in a number of regional reports from various organizations and institutes suggest that between 20% and 50% of all women have suffered violence from their partner at some time in their relationship and that 25% are now living or have lived in a violent situation (Eriksson, 1997; WHO, 1996, 1998a). Despite its invisibility, more and more studies recognize the negative impact of violence against women on a wide range of important health issues, such as safe motherhood, family planning family planning Use of measures designed to regulate the number and spacing of children within a family, largely to curb population growth and ensure each family’s access to limited resources. , mental health, chronic illnesses, etc. (WHO, 1998b; n.d./1999). For many women victims, health professionals are their most important source of support. In this article we will look at the mental health repercussions repercussions npl → répercussions fpl repercussions npl → Auswirkungen pl of one type of gender-based violence--domestic violence. For a working definition, we return to the glossary of the European Commission: Domestic violence or family violence is defined as "any form of physical, sexual or psychological violence which puts the safety or welfare of a family member at risk and/or the use of physical or emotional force or threat of physical force, including sexual violence, within the family or the household. Includes child abuse, incest, wife battering and sexual or other abuse of any member of the household." Of all these forms of domestic violence, this article will focus on what the European Commission terms wife battering and defines as "violence against women by their partner." Repercussions of Violence Against Women Recently, WHO (1998a, 1998b; n.d./ 1999) established the following categories of repercussions of violence against women: A. Fatal outcomes: suicide, homicide, maternal mortality, AIDS. B. Non-fatal outcomes: a. To physical health: injuries; unwanted and/or early pregnancy early pregnancy Obstetrics First trimester of pregnancy ; abortion or other injuries occurring during pregnancy; sexually transmitted diseases Sexually transmitted diseases Infections that are acquired and transmitted by sexual contact. Although virtually any infection may be transmitted during intimate contact, the term sexually transmitted disease is restricted to conditions that are largely ; gynecological gynecological /gy·ne·co·log·i·cal/ (-kah-loj´i-k'l) gynecologic. problems; pelvic inflammatory disease pelvic inflammatory disease (PID), infection of the female reproductive organs, usually resulting from infection with the bacteria that cause chlamydia or gonorrhea. ; chronic pain (pelvic, headache, etc.); irritable bowl syndrome; alcohol or drug abuse; self-destructive behaviors (smoking, unprotected sex Unprotected sex refers to any act of sexual intercourse in which the participants use no form of barrier contraception. Sexually transmitted infections Specifically, unprotected sex , etc.); permanent disability; asthma; and general vulnerability to diseases or severe health problems. b. To mental health: depression; fear; anxiety; low self-esteem; sexual dysfunction sexual dysfunction Inability to experience arousal or achieve sexual satisfaction under ordinary circumstances, as a result of psychological or physiological problems. ; eating disorders eating disorders, in psychology, disorders in eating patterns that comprise four categories: anorexia nervosa, bulimia, rumination disorder, and pica. Anorexia nervosa is characterized by self-starvation to avoid obesity. ; obsessive-compulsive disorder obsessive-compulsive disorder Mental disorder in which an individual experiences obsessions or compulsions, either singly or together. An obsession is a persistent disturbing preoccupation with an unreasonable idea or feeling (such as of being contaminated through shaking ; multiple personality disorder Multiple Personality Disorder Definition Multiple personality disorder, or MPD, is a mental disturbance classified as one of the dissociative disorders in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). ; posttraumatic stress disorder Posttraumatic stress disorder An anxiety disorder in some individuals who have experienced an event that poses a direct threat to the individual's or another person's life. . A number of hypotheses have been formulated as to the possible routes by which violence may affect health (Koss, Koss and Woodruff, 1991), including: 1. Reduced natural resistance or immunity caused by violence-related stress; 2. Changes in health habits in response to the trauma, including lack of attention to one's own health and assumption of greater risks; 3. Undocumented secondary physical damages caused by violence; 4. Chronic over-stimulation due to post-traumatic stress disorder post-traumatic stress disorder (PTSD), mental disorder that follows an occurrence of extreme psychological stress, such as that encountered in war or resulting from violence, childhood abuse, sexual abuse, or serious accident. ; 5. Focalization fo·cal·ize tr. & intr.v. fo·cal·ized, fo·cal·iz·ing, fo·cal·iz·es 1. To adjust or come to a focus. 2. To bring or be brought to a focus; sharpen. 3. of internal sensations; 6. Erroneous interpretation of symptoms, including normal psychological sensations accompanying emotional distress emotional distress n. an increasingly popular basis for a claim of damages in lawsuits for injury due to the negligence or intentional acts of another. Originally damages for emotional distress were only awardable in conjunction with damages for actual physical harm. ; and 7. Interaction with a biomedically-oriented health care system. Resnick, Acierno and Kilpatrick (1997) propose a model which suggests different potential mechanisms through which the violent episode could augment the risk of health problems (see Figure 1). [FIGURE 1 OMITTED] Although this model includes both physical as well as mental health problems, in this article we will examine only issues related to mental health. Elsewhere, we have reviewed the available data on the repercussions of abuse on the physical health of women (Ferrer and Bosch, 2000). The Link Between Domestic Violence and Mental Health As the literature on the subject indicates, the psycho-pathological disturbances most frequently associated with abuse are depression and posttraumatic stress disorder. Other relatively frequent mental disturbances in women victims of domestic violence are: anxiety-related disorders, such as panic attacks panic attacks, n.pl distressing episodes where an individual experiences palpitations, anxiety, apprehension, sweating, trembling, etc. Can last several minutes and recur unpredictably. or obsessive-compulsive disorder (Jaffe et al., 1986; Follingstad et al., 1991; Goodman, Koss and Russo, 1993; Zubizarreta et al., 1994; Roberts et al., 1998); brief reactive disturbances, dissociative dissociative /dis·so·ci·a·tive/ (-so´se-a´tiv) pertaining to or tending to produce dissociation. states or psychoses (Roberts et al., 1998); eating disorders, such as anorexia and bulimia bulimia: see eating disorders. (Walker, 1984); and alcoholism and drug dependencies (Roberts et al., 1998). The available data suggest that women who suffer from abuse are between four and six times more likely to need psychiatric treatment than other women (WHO, 1998a). Recently, the Women's Institute of Spain's Ministry of Labor and Social Affairs surveyed a broad sample of women and found that abused women most often manifested the following symptoms: These data coincide with the impressions gathered from the scientific literature on the subject. Given that depression and posttraumatic stress disorder are the most frequently cited psycho-pathological disturbances in these women, we will concentrate on these two problems. Depression The high rate of depression among victims of abuse is similar to that found in other victims of traumatic events. Diverse studies in this respect (Walker, 1984; Jaffe et al., 1986; Sato and Heiby, 1991, 1992; Cascardi and O'Leary, 1992; Goodman, Koss and Russo, 1993; Zubizarreta et al., 1994; Campbell, Sullivan and Davidson, 1995; Echeburua et al., 1997; Roberts et al., 1998) indicate that between 47% and 80% of abuse victims suffer from depression. Some characteristics of wife battering are directly linked to the appearance of depressive disturbances (Staats and Heiby, 1985). For example, the abuser punishes the victim when she shows adaptive responses (expressing fear, anger, looking for Looking for In the context of general equities, this describing a buy interest in which a dealer is asked to offer stock, often involving a capital commitment. Antithesis of in touch with. help). Any attempt by the victim to defend herself may increase the intensity of the abuse. As a result, a battered woman will be less likely to recur to these adaptive responses in the future. When the victim tries to end the relationship, the risk of further abuse and even murder increases. Abuse is even more damaging when it is inconsistent or accompanied by sporadic reinforcements, that is, when a particular conduct is punished on some occasions and not on others. On the other hand, the abuser often prevents the victim from recurring to her habitual sources of reinforcement. isolating her from her friends, her hobbies, even her work. This social isolation favors the dependence on the aggressor AGGRESSOR, crim. law. He who begins, a quarrel or dispute, either by threatening or striking another. No man may strike another because he has threatened, or in consequence of the use of any words. and converts him into the only source of social and material comfort. In addition, by reinforcing certain nonadaptive behaviors, the depression is deepened and maintained. Battered women receive positive reinforcement positive reinforcement, n a technique used to encourage a desirable behavior. Also called positive feedback, in which the patient or subject receives encouraging and favorable communication from another person. from their partners for remaining submissive, passive and dependent--all characteristics of depression. Continuous abuse can have serious effects on self-esteem, increasing the vulnerability to depression Post-traumatic stress disorder It has been suggested recently that a diagnosis of post-traumatic stress syndrome provides an appropriate description of the psychological consequences of domestic violence on women. The American Psychiatric Association The American Psychiatric Association (APA) is the main professional organization of psychiatrists and trainee psychiatrists in the United States, and the most influential world-wide. Its some 148,000 members are mainly American but some are international. introduced this disorder as a diagnostic category in the third edition of its Diagnostic and Statistical Manual of Mental Illnesses (DSM-III; APA (All Points Addressable) Refers to an array (bitmapped screen, matrix, etc.) in which all bits or cells can be individually manipulated. APA - Application Portability Architecture , 1985), with the aim of combining a set of diagnoses which previously had been considered separately (rape trauma syndrome rape trauma syndrome Psychology An acute stress reaction to a life-threatening situation in which sexual assault was attempted or successful. See Date rape, Rape, Sexual assault. , war neurosis, survivor's syndrome, etc.) The new term encompasses a set of anxiety symptoms which manifest themselves in a similar way in most individuals who confront a psychologically traumatic event outside the usual framework of human experience. This diagnosis is applicable to situations such as natural disasters and accidents. In the most recent edition of this manual (DSM-IV DSM-IV Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). This reference book, published by the American Psychiatric Association, is the diagnostic standard for most mental health professionals in the United States. , 1995), emphasis is shifted toward the reaction of the individual and away from the type of traumatic event. The criteria proposed for this diagnosis include: exposure to a traumatic event; reliving the event through recurrent thoughts or dreams; persistent avoidance of stimuli associated with the trauma; dulling or numbing associated with regular life activities; persistent activation symptoms; and the prolonging of these alterations (which provoke significant discomfort or dysfunction) for longer than one month. This modification permits the inclusion in this clinical diagnosis not only of victims of extraordinary or freak events but also of other types of victims, such as abused women (Echeburua and Corral corral a small fenced-in enclosure with high, wooden fences, suitable for holding cattle or horses. corral system a management system in which range cattle are put into corrals and fed hay for a period when the environment is most , 1996). The few studies of symptoms of posttraumatic posttraumatic /posttrau·mat·ic/ (post?traw-mat´ik) occurring as a result of or after injury. post·trau·mat·ic adj. Following or resulting from injury or trauma. stress in victims of abuse tend to suggest that an important percentage (between 45% and 55%) fulfill the criteria required to confirm a diagnosis (Walker, 1989; Houskamp and Foy, 1991; Dutton, 1992; Goodman, Koss and Russo, 1993; Villavicencio, Sebastian and Ruiz, 1994; Zubizarreta et al., 1994; Echeburua et al., 1996, 1997). Certain circumstances related to the abuse are predictors of the appearance of post-traumatic stress disorder (Echeburua and Corral, 1996). Among these factors are: prolonged duration of the traumatic situation; situations which threaten life or serious injury to the victim; low level of social support; and economic problems. Another aggravating factor is the occurrence of the traumatic experience in an area supposedly "safe" for the victim, such as her house or place of work. In addition, as DSM-IV (1995) suggests, this disturbance can become especially serious or long-lasting when the stress-provoking agent is another human being. The probability of post-traumatic stress disorder increases in accordance with the level of intensity or physical proximity of the source of stress. When the cause of the trauma is another person, the following symptoms can appear: emotional imbalance; impulsive and self-destructive behavior; dissociative symptoms; sleep disorders Sleep Disorders Definition Sleep disorders are a group of syndromes characterized by disturbance in the patient's amount of sleep, quality or timing of sleep, or in behaviors or physiological conditions associated with sleep. ; feelings of uselessness, shame, desperation or despair; sensation of constant danger or vulnerability; loss of previous beliefs; hostility; social withdrawal; deterioration of interpersonal relations; and changes in personality. All these aggravating circumstances--prolonged aggression over time; life-threatening situations; abuse occurring within a supposedly safe area; physical proximity of the aggressor--are present among victims of domestic violence. In addition, the abuser is (or was) someone that they loved or respected. The batterer is the person with whom they have chosen to share their life, with whom they share lifelong goals and plans. It is precisely the level of emotional proximity that aggravates the intensity of the experience (Goodman, et al., 1993). Finally, it is important to remember that not all victims of traumatic situations suffer from this disorder. The psychological reaction to an experience depends on the intensity of the trauma, the circumstances surrounding the event, the victim's age, history of previous abuses, previous emotional stability, psychological resources, self-esteem, social and family support, and current emotional relationships (Echeburua and Corral, 1996). Some Conclusions Victims of domestic violence suffer physical and mental health consequences, the latter concentrated in depression and post-traumatic stress disorder. Understanding the consequence of violence for the women also can indicate the most appropriate types of interventions in these cases. Nevertheless, beyond the undoubted usefulness of these findings, Villavicencio and colleagues, among others (Villavicencio and Batista, 1992; Villavicencio and Sebastian, 1999; Roberts et al., 1998), note that these mental health problems are usually the consequence of the abuse itself. However, the cause is not always explicitly identified in the diagnosis, post-traumatic stress disorder being the most obvious exception. In the case of battered women, an emotionally-supportive social environment, based on the recognition of abuse as a crucial social problem, constitutes an important factor in an eventual psychological recovery. Goodman et al. recall (1993) that because battered women are not a uniform group, the consequences of abuse vary. Some suggest that the variety and severity of the symptoms and consequences of abuse on a woman's mental health will be related to the frequency of the abuse, the presence of emotional abuse, adjustment to the traditional gender role, the perception of the violence as more or less lethal, family history of abuse, etc. (Follingstad, et al., 1991; Goodman et al., 1993). All these factors must be taken into account. Table 1. Symptoms of Women Victims of Abuse Symptom Abused Women (%) All Women (%) Headaches 51.8 43.3 Pain in back or joints 72.1 64.2 Flu 27.3 21.8 Chronic fatigue 27.6 16.8 Insomnia 47.2 34.9 Mood swings 72.4 53.1 Desire to cry for no reason 50.3 31.7 Sadness 40.6 21.3 Anxiety or anguish 52.3 32.0 Irritability 54.2 35.1 Lack of libido 44.0 23.6 Source: Survey from the Instituto de la Mujer (Women's Institute) as reported in El Pais, March 9, 2000 (Iribar, 2000b). 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